Contact 1 — Dr. Trillion Small, LMFT-S

LMFT Supervision Application

Please complete this application If you are seeking an LMFT supervisor and would like to explore if you and I would be a good fit.

The process: (1) Complete this Initial Application, (2) Complete a video interview with me, (3) Complete the final questionnaire + selected self-report assessments, and then if we agree that we are a good fit then (4) schedule a meeting to discuss logistics (meeting date/time, fee, expectations, goals, etc…)

Name

First Name

Last Name

Please list all url's for your web and social media presence.

Please include any websites or social media links to your personal pages.

What is your highest degree earned?

What school (s) have you attended and what degree did you earn at each school?

Have you successfully passed the AMFTRB?

What age groups do you prefer working with?

Is there a disorder or presenting issue that you are most comfortable working with?

Explain your answer.

Is there a particular issue that you know you’d be uncomfortable working with? (for example: working with a person with a particular diagnosis or presenting issue?)

Explain your answer.

What theories and modalities are you most drawn to?

What therapy modalities would you like to explore and learn more about?

Have you ever personally been to therapy? If yes, how long did you work with your therapist? If no, are you interested in going to therapy?

The services I prefer to provide are:

Check all that apply.

Individual therapy

Couple therapy

Family therapy (3 or more people)

Group therapy

Are you currently being supervised by another supervisor?

If you answered "no" to the above question, have you worked with an LMFT-supervisor in the past?

Previous Supervisor's Contact Details: Please list the name, email, phone #, and license # of all previous supervisors

If this is not applicable because you've never worked with an LMFT-S, LPC-S, etc... then type N/A

Consent to Contact Your Previous Supervisor

I understand that you may contact my previous supervisor and I give consent for you to contact my previous supervisor. Consent is required if you have worked with an LMFT-S before.

I declare that I have never worked with another LMFT-S, LPC-S, or any form of supervision related to my. mental health training in the past or present.